Provider Demographics
NPI:1699022111
Name:KIM, BRIAN BYOUNGSOO (MPT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:BYOUNGSOO
Last Name:KIM
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1962 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6635
Mailing Address - Country:US
Mailing Address - Phone:714-488-6773
Mailing Address - Fax:
Practice Address - Street 1:1962 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6635
Practice Address - Country:US
Practice Address - Phone:714-488-6773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA365442251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic